The role of antibiotics and probiotics in pouchitis

Pouchitis is a non-specific inflammation of the ileal reservoir and the most common complication of proctocolectomy with ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis. Its frequency is related to the duration of the follow up, occurring in up to 50% of patients 10 years after IPAA in large series from major referral centers. Treatment of pouchitis is largely empirical and only small placebo-controlled trials have been conducted. The rationale for using probiotics and antibiotics in pouchitis is based on convincing evidence that implicates intestinal bacteria in the pathogenesis of this disease. Probiotics are living organisms, which, upon ingestion in certain numbers, exert health benefits beyond inherent basic nutrition. VSL#3, a highly concentrated cocktail of probiotics has been shown to be effective in the prevention of pouchitis onset and relapses. Antibiotics are the mainstay of treatment of pouchitis, and metronidazole and ciprofloxacin are the most common initial approaches, often with a rapid response. The use of antibiotics in pouchitis is largely justified although proper controlled trials have not been conducted.